What Is POTS?

Postural Orthostatic Tachycardia Syndrome, or POTS, is a form of autonomic nervous system dysfunction characterized by a significant increase in heart rate—typically over 30 beats per minute in adults or over 40 bpm in adolescents—within 10 minutes of standing up, without a corresponding drop in blood pressure. This abnormal cardiovascular response leads to symptoms such as lightheadedness, palpitations, and fatigue. POTS significantly disrupts daily life and may result in long-term disability if not properly managed.

Estimates suggest that around 1 to 3 million people in the United States live with POTS, although the actual number may be higher due to underdiagnosis. It commonly affects individuals assigned female at birth and typically develops between the ages of 15 and 50. Although it is not considered fatal, the impact on quality of life can be profound.

Types of POTS

POTS manifests in several different forms, depending on the underlying mechanisms. The two most recognized subtypes are:

  • Neuropathic POTS: This form is associated with peripheral denervation, particularly in the lower limbs, leading to blood pooling and an insufficient return of blood to the heart. This causes compensatory tachycardia when the person stands up.

  • Hyperadrenergic POTS: Characterized by an excessive release of norepinephrine upon standing, leading to both elevated heart rate and increased blood pressure. This subtype may present with additional symptoms such as tremors and anxiety.

Some researchers also recognize other variants such as hypovolemic POTS (associated with low blood volume) and autoimmune POTS, which may overlap with other immune system dysfunctions.

Common Symptoms

POTS presents with a diverse range of symptoms, many of which overlap with other medical conditions. The core diagnostic marker is a rapid increase in heart rate upon standing. Other symptoms include:

  • Orthostatic intolerance: Feeling faint, dizzy, or nauseated when standing

  • Fatigue: Often chronic and debilitating

  • Palpitations: A sensation of a racing or pounding heart

  • Brain fog: Difficulty concentrating, short-term memory issues, and mental fatigue

  • Headaches or migraines

  • Blurred or tunnel vision

  • Shakiness or tremors

  • Gastrointestinal problems: Including nausea, bloating, constipation, or diarrhea

  • Exercise intolerance: Reduced capacity for physical exertion

  • Chest discomfort or shortness of breath

  • Cold or discolored extremities

Symptoms may be exacerbated by hot environments, dehydration, menstruation, or after meals.

Potential Causes

The exact cause of POTS is not well understood, and it is likely multifactorial. Various triggers and risk factors have been associated with its development:

  • Viral or bacterial infections: Many patients report the onset of symptoms after an acute illness, including Epstein-Barr virus or COVID-19

  • Trauma: Including concussion, car accidents, or surgeries

  • Pregnancy: Hormonal fluctuations may initiate symptoms

  • Prolonged bed rest: Especially after surgery or severe illness

  • Genetic predisposition

  • Autoimmune disorders: POTS is commonly associated with conditions like lupus, Ehlers-Danlos Syndrome (EDS), Sjögren’s syndrome, and Hashimoto’s thyroiditis

Researchers are investigating whether immune system dysfunction plays a central role in the development of POTS.

Risk Factors

Although anyone can develop POTS, several factors may increase susceptibility:

  • Sex: Females are diagnosed more frequently than males

  • Age: Most cases begin between the ages of 15 and 50

  • Recent infections or illness

  • Family history of autonomic dysfunction

  • Presence of other chronic illnesses

Environmental and lifestyle factors such as chronic stress, poor sleep, or overtraining in athletes may also contribute.

Diagnosis

Diagnosing POTS involves ruling out other conditions with similar presentations and confirming abnormal heart rate responses through specific tests. Common diagnostic tools include:

  • Active stand test: The patient lies flat for 10 minutes and then stands. Heart rate and blood pressure are recorded at intervals.

  • Tilt table test: The patient is strapped to a table that moves from horizontal to vertical to simulate postural changes while monitoring cardiovascular responses.

  • Electrocardiogram (ECG): Checks for irregular heart rhythms or arrhythmias

  • 24-hour Holter monitoring: Records heart activity throughout the day

  • Blood tests: Assess thyroid function, electrolyte levels, blood volume, and autoantibodies

  • QSART or other autonomic function tests: Evaluate sweating and nerve responses

Diagnosis is confirmed if there's a heart rate increase of at least 30 bpm (40 bpm for teens) within 10 minutes of standing, without a drop in blood pressure.

Treatment Options

POTS treatment focuses on symptom management, as no universal cure exists. A comprehensive plan typically combines lifestyle modifications, pharmacological support, and sometimes psychological therapy.

Lifestyle Interventions

  • Hydration: Drink 2–3 liters of fluid daily

  • Salt intake: Increase sodium consumption (up to 10g/day) under medical supervision

  • Physical activity: Begin with recumbent exercises such as rowing, swimming, or cycling, and progress gradually

  • Compression garments: Waist-high compression stockings help reduce blood pooling

  • Elevate bed head: Sleeping with a raised head (about 6–10 inches) helps regulate fluid balance

  • Avoid triggers: Heat, long periods of standing, and large meals can worsen symptoms

Medications

Several medications may be used, tailored to the individual's symptoms and response:

  • Fludrocortisone: A corticosteroid that increases fluid retention and blood volume

  • Midodrine: Causes vasoconstriction to raise blood pressure

  • Ivabradine: Reduces heart rate in hyperadrenergic POTS

  • Beta-blockers (e.g., propranolol): Control tachycardia, especially in younger patients

  • Pyridostigmine: Enhances neurotransmission in the parasympathetic nervous system

Other options like SSRIs or SNRIs may be used when POTS overlaps with anxiety or depression.

Psychological Support

Living with POTS can be mentally taxing. Many patients benefit from:

  • Cognitive Behavioral Therapy (CBT): Helps manage anxiety, depression, and maladaptive thoughts related to chronic illness

  • Support groups: Online and local communities provide emotional support and practical advice

  • Mindfulness and relaxation techniques: Yoga, meditation, and breathing exercises can enhance resilience

Conditions Associated With POTS

POTS often coexists with other chronic or autoimmune conditions:

  • Ehlers-Danlos Syndrome (EDS): A connective tissue disorder often seen in POTS patients

  • Chronic Fatigue Syndrome (ME/CFS)

  • Mast Cell Activation Syndrome (MCAS)

  • Fibromyalgia

  • Irritable Bowel Syndrome (IBS)

  • Autoimmune thyroid disease

Understanding and treating these overlapping disorders is essential for comprehensive POTS management.

Living With POTS

Adapting to life with POTS requires patience, consistency, and education. Many patients report an improvement in quality of life through a combination of treatments. While about 50% see significant symptom reduction within 1–3 years, others may continue to experience fluctuations.

Strategies for managing daily life include:

  • Keeping a symptom journal to track triggers

  • Building a multidisciplinary care team (cardiologist, neurologist, physical therapist, psychologist)

  • Advocating for workplace or school accommodations

  • Educating family and friends to build a strong support network

With growing awareness and ongoing research, the future for POTS patients is increasingly hopeful.